Every time I turn around there is another shell to watch in the game of rebate pricing. And just when you thought the pharmacy benefit manager (PBM) pricing structure couldn’t get more convoluted, it is…
Most employers are already aware that PBMs provide significant rebates every time brand drugs are dispensed. As the cost of prescription drugs have increased so have those rebates, with some groups receiving three times the rebate levels they achieved a decade ago.
Well it’s no longer just about monitoring the per-script rebate guarantee for retail and mail order drugs. The newest kink is separate guarantees for retail drugs at 90 days and specialty brands. So categorizing drugs appropriately won’t just impact discount guarantees and dispensing fees, but now rebates as well. One client of mine saw a $700k swing just on the basis of the PBM classifying certain specialty HIV drugs as brand.
We continue to wait for a coherent response from Washington on the unsavory world of PBM pricing. But until we do, make sure to read the fine print.